@shivam_mundra: Community reach out program; awareness events; peers @HealthStandards @ShimCode @nxtstop1: Other than locales > think who is most appropriate, might be most successful at identifying those most in need~ @nxtstop1: Choices 4 who best to ID range from healthcare personnel to community "ambassadors" - trusted voices, non-health, within community @lesliecozatt: Community partners are key! Senior and community centers. Here's a school example. https://t.co/6nrwwh1JHy https://t.co/yJ6RZeeAMd @resultant: Physical Therapists and other "after care" services that get cut off when insurance "runs out" but patient not back to normal @adamrichsearch: Having a connection to community health workers to pinpoint valuable information on patient non-medical needs. @jimmie_vanagon: A very empathetic, organized office nurse with tools at fingertips can be very instrumental to help in this endeavor @nxtstop1: Data mining, social media mining R options but these may be populations that fall into the #digitaldivide, limited wifi, no PC @glhc_hie: From the TOTALLY Self-Serving promotion department - Via Health Information Exchange!

Great #HITsm minds think alike!

@shimcode: Exchange and public enrollment applications could include questions to identify people w/ certain needs

@shereesepubhlth: Some states are taking a proactive approach by offering Single-point of Entry SPE platforms for individs. And

Via Analytics & Big Data

@mloxton: See increasing use of analytics of social media to identify at-risk individuals and locations @shivam_mundra: #DataAnalytics can play an important role in identifying individuals #behavioralhealth @matt_r_fisher: How about mining data from general consumer oriented places. With analytics bet could identify from purchase habits. @healthcora: Easy one for #HealthAnalytics - look for billing codes that help to identify the use of these services, or scrape free text notes @wareflo: Computer simulation plays role in modeling impact of social programs. Agent based simulation literally models agent something-flow @mloxton: I tried R-Sentiment a year or so back, was surprised how good it was at extracting mood dimensions from ton of tweets @ebukstel: Zip Code are most important determinant of health, How can HCPs integrate pt condition into care? @ebukstel: Agree. There was also a focus on smoking cessation, and I don't smoke. Not nearly expansive enough @shereesepubhlth: What if we address social/emotional needs in same way we approach fall precautions? @matt_r_fisher: Yes, why not have function that examines EMR data and then applies to broader search. Then have targeted follow up. @matt_r_fisher: Just look at Gmail for example. It knows things about you before you do sometimes. @wareflo: At its most basic, simulating agents means modeling them as stochastic sequences of activities interacting w/environment (-flows) @mandibpro: Can infer #SDoH factors from zip+4 geography (+4 CRITICAL), good for prediction, ~meh specific patient needs. @uiandme: Address hi-level barriers: lack of info about where to get treated, lack of access to transportation, and lack of identification Via Apps, Devices, Smart Phones & The IoT

@wareflo: Today, w/advances in Internet of Things and ambient computing, can feed activity data from entire communities to simulations of them @scottyweitzman: I one day hope that we can use new tools to drive down care costs. So we can get the care we need. @scottyweitzman: A mobile device can become a powerful tool in finding out data mapping out what/why people are missing ops to get help. @mloxton: did anyone notice that FaceBook now have a flag for suicidality? Alerts a team who reach out @scottyweitzman: Study trends about what services they ignore and why so. #Tech can help deliver easier service to them @mandibpro: Who knows about 211? https://t.co/V3KvUBMKr0 ? Met founder @ #HIMSS16, AWESOME service. @shereesepubhlth: Great example. I think people forget about 211 because it’s not widely promoted. "Out of sight . . . Out of mind. @mandibpro: Physicians diagnosticians. #Tech could help, if resources pertinent to patient could pop up in #EHR workflow. @cathysusk: But #socialmedia could replace a lot of phone contact right? @shereesepubhlth: SPE platforms allow users to leverage HIT and use to find all relative state support services in one place. But Funding and Reimbursement Must be Addressed

@shereesepubhlth: Transitional care services are the under-utilized, under-funded, under-promoted model of our day. Not a good look

@mandibpro: Tragic: Non-profits who put donation $ to services rather than advertising or C-pay have hard time w/ growth. It's the Individual Who It's All About

@matt_r_fisher: Seems like it's just a matter of engaging people. Can find someone who could benefit anywhere.

@unknown: How do we ask #sdoh questions without offending the patient? Pretext needed @adamrichsearch: Also, asking open-ended questions helps to elicit more than just medical info. Gives an idea of what the individual truly needs. @jimmie_vanagon: Spending more time with each and every patient, slow down/listen and connect needs based on local resources available @cathysusk: How can u help anyone that doesn't want help? @johnmtrader: Human interaction can be such an elusive beast in the digital age. Really takes effort now. @mandibpro: PEOPLE. Exactly. Human interaction. There are systematic ways to analyze interactions, but people best. @mandibpro: It does. We're raising a generation that won't know how to hold an in-person meeting or maintain eye contact. @mandibpro: Decline of nuclear family, let alone community ties and geographically diverse extended families, challenge. @shimcode: It'll take some time and conscious outreach to build trust so people voluntarily self-report functional limitations @nxtstop1: I prefer the community approach for some regions, esp. those which may possibly have lower trust of mainstream healthcare/medicine @shereesepubhlth: Sadly enough, those needing non-medical support don't always know where to look for it. We all have to be advocates. Grab Bag of Thoughts on Topic #1

@glhc_hie: Integrated care models like the one we highlighted at #HIMSS16 are popping up all over the country! Real ACTION! Imagine THAT!

@ebukstel: HCPs do a poor job in tracking medication compliance, especially when pt doesn't have $$ for meds.

@shereesepubhlth: Services that help inds save on meds aren't promoted by health depts and state HIEs. Ex @watertreehealth

@wareflo: Operations research/Management science #ORMS approaches to social program evaluation optimize workflow, at some level of abstraction

@jimmie_vanagon: I think discussions like this, taken down unintended paths can be very revealing ;)

But Wait! There's More Coming!I'm currently curating tweets from the remaining five topics that were discussed in the tweetchat and will post those over the next day or two. For more information on healthcare data, technology and services, consider following me on Twitter.